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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801977
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:41:01 PM

Document Has Been Signed on 09/26/2023 02:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:STOCKSTILL HOUSEFACILITY NUMBER:
216801977
ADMINISTRATOR:NATALIA MEYERSONFACILITY TYPE:
740
ADDRESS:12051 STATE ROUTE 1TELEPHONE:
(415) 663-0722
CITY:POINT REYES STATIONSTATE: CAZIP CODE:
94956
CAPACITY: 8CENSUS: 8DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Natalia Meyerson, AdministratorTIME COMPLETED:
02:50 PM
NARRATIVE
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License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA was welcomed by Administrator Natalia Meyerson. There is a total of 8 residents with 4 residents currently on Hospice.

LPA toured the facility on 9/26/2023 at 9:00 AM with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 8/22/2023 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually. LPA is requesting a copy of annual smoke/alarm inspection. LPA observed Carbon monoxide detector that was found to be operational during the visit. Facility has a generator that will start if there is a power shut out. Hot water temperature measured between 109 degrees F and 113.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 9/26/2023 at 9:15 AM. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food is available for residents any time of the day. There are activities schedule for residents' weekly. Toxins are stored in locked bathroom cabinets & locked kitchen cabinet under sink. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 9/26/2023.

Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2023 02:41 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/26/2023 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review & interview, the licensee did not comply with the section cited above in 5 out of 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Facility to submit written plan for new staff training on how facility will ensure that staff has required training and how the Department will be able to audit training.
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and interview, the licensee did not comply with the section cited above in 5 out of 5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Facility to submit written plan for ongoing staff training on how facility will ensure that staff has required training and how the Department will be able to audit training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2023 02:41 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/26/2023 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation residents medications had been prepoured into plastic containers which were to be given to the residents as stated. Medications are to remain in original containers. This is a potenitial risk to health & safety and/or personal rights risk to residents in care.
POC Due Date: 09/29/2023
Plan of Correction
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 Licensee to submit policy and procedures regarding storage of medications, submit plan of correction by 9/29/23.
Licensee to ensure all staff are retrained in medication procedures, submit proof of training by 9/29/23.
Type B
Section Cited
CCR
87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, two out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in two out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 10/13/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977
VISIT DATE: 09/26/2023
NARRATIVE
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A sample review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed a random sample of resident’s files at 11:15 AM on 9/26/2023 and learned that 4 out of 5 residents have an updated reappraisal/needs & care plan on file (see LIC809D) & 5 out of 5 residents have updated medical assessments at this time as required by Title 22 Regulation.

Medications were centrally stored in a locked medication cabinet in the facility medication room. The Medications of 2 out of 2 residents were found to be pre poured and records do not match medication counts per according to physicians’ directions on 9/26/2023 at 1:45 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be inaccurate (see LIC 809D).

LPA conducted a sample reviewed of staff records at 1:15 PM on 9/26/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. However, Direct care staff haven’t received the additional training requirements as per Title 22 Regulations and H&S Code (see LIC809D). LPA was presented with proof of CPR & 1st Aid certification for staff; although 2 of 5 staff do not have required First Aid certification (see LIC809-D). Natalia Meyerson Administrator Certificate # 6016748740 expires on 5/17/2024.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted with the last one being conducted on 8/21/2023.



Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/26/2023 02:41 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/26/2023 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465(h)(6)Incidental Medical & Dental:The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications ...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit & interview the license didn't comply w/this section on 2 of 2 residents which poses a potential health, safety risk to clients in care. LPA reviewed medication records had no complete CSMR.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee to ensure that all residents' medications are entered on a Centrally Stored Medication Record. Facility to provide CCL with copies of CSMR for all residents' medications by POC date of 10/13/2023. **LPA guided staff to fill out forms.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977
VISIT DATE: 09/26/2023
NARRATIVE
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LPA Hansen is requesting Licensee to update and submit the following documents by 10/13/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Control of Property (Deed or Lease)
Copy of Certificate of Liability Insurance
Copy of last Annual smoke/alarm inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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